A Comparative Study of an Integrated Ultrasonic/Bipolar Sealing Device versus an Articulating Bipolar Sealing Device for Laparoscopic Liver Surgery

Abstract

Purpose: Hemostatic devices are able to seal and cut tissue with the application of different energy modalities, and are routinely used in open and laparoscopic liver surgery (LLS). The aim of this study is to compare the outcome of Thunderbeat (TB), an integrated ultrasonic/bipolar sealing device, versus Enseal (ES), an articulating bipolar sealing device, in LLS. Methods: A retrospective analysis of a prospectively maintained database was conducted in a single center from September 2011 to September 2020. The primary endpoint was evaluation of difference in blood loss between the two hemostatic devices. Secondary endpoints consisted of complications, operative time, hospital stay, and mortality. Results: 352 patients were identified who underwent LLS, either by using TB (n=105) or ES (n=247). The TB and ES group were comparable in terms of sex, comorbities, extension of resection, and surgical difficulty scores (IWATE and Southampton). Median blood loss was significantly lower with TB (50 mL (IQR: [20-120]) compared to ES (100 mL (IQR: [50-250]) (p<0.0001). The amount of blood loss was highest for anatomical major and lowest for minor resections, and increased proportionally with difficulty scores. Use of cavitron ultrasonic surgical aspirator (CUSA) was associated with an increase in blood loss in both TB and ES (100 mL (IQR: [50-300]) vs. 175 mL (IQR: [100-400]); p<0.0001). Median operative time was considerably shorter in TB (115 min (IQR: [45-300])) compared to ES (140 min (IQR: [40-370])) (p=0.0008). The Pringle maneuver was more often applied in TB (27.6%) compared to ES (13.8%) (p=0.0036). However, by adjusting for variables influencing blood loss in a generalized linear model, the type of hemostatic device remained a significant contributing factor in blood loss (p=0.0164). The postoperative complication rate was similar for bleeding (TB 0% vs. ES 1.2%; p=0.5574) and biliary leak (TB 1.0% vs. ES 1.6%; p=1.0000), and there was no significant difference in 90-day mortality (TB 0% vs. ES 0.8%; p=1.0000). Median hospital stay was shorter for TB compared to ES (2 days (IQR: [1-4]) vs. 4 days (IQR: [3-6]); p<0.0001) although this might be explained by the introduction of an enhanced recovery after surgery (ERAS) clinical pathway in June 2015. Conclusion: The integrated ultrasonic/bipolar sealing device is superior compared to the articulating bipolar sealing device in LLS in terms of perioperative blood loss without an increase in complications.